Sino-Nasal Outcome Test (SNOT-20)

Sinus Survey

The following questionnaire is intended to help define your symptoms and provide valuable information and insights for Dr. Leeman. Answer the questions, rating to the best of your ability the problems you have experienced over the past two weeks. After completing the survey, please print this page and bring it to your appointment.

1. Consider how severe the problem is when you experience it and how frequently it happens, please rate each item below on how “bad” it is by ticking the radio button that corresponds with you feel.

No problem

Very
mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

0

1

2

3

4

5

1. Need to blow nose

2. Sneezing

3. Runny nose

4. Cough

5. Post-nasal discharge

6. Thick nasal discharge

7. Ear fullness

8. Dizziness

9. Ear pain

10. Facial pain / pressure

No problem

Very
mild problem

Mild or slight problem

Moderate problem

Severe problem

Problem as bad as it can be

0

1

2

3

4

5

11. Difficulty falling asleep

12. Wake up at night

13. Lack of sleep

14. Wake up tired

15. Fatigue

16. Reduced productivity

17. Reduced concentration

18. Frustrated / restless / irritable

19. Sad

20. Embarrassed

SCORE:

Score

Evaluation

Recommended Next Step

0 to 10

No problem to mild problem

No actions necessary or symptoms can be treated with OTC medication.

11 to 40

Moderate problem

An appointment with a specialist or your PCP is recommended and/or prescription medicine can be taken to treat symptoms.

41 to 69

Moderate to severe

An appointment with a specialist or your PCP is recommended and/or prescription medicine can be taken to treat symptoms.

70 to 100

Severe to “as bad as it can be”

And appointment with a specialist is recommended, treatment to be determined by doctor. Possible surgical candidate.

*The SNOT score evaluation is to be used as a guide and not a physician’s diagnosis. Treatment to be determined by doctor upon appointment.